Nephrotic Syndrome in 20 yo

HIV patient

1
Data Base
Male / y.o
Chief Complaint : Shortness of breath
Present Medical History :
The patient has suffered from shortness of breath
since 1 week before admission, and get worse in the last 2
days. The shortness of breath get worse when the patient
do the activity and also happen at night when the patient
sleep. He has also suffered from weakness for 2 days.
The pastient also has suffered from cough since 1
week before admission, with the whitish sputum. He also
suffered from nausea and vomiting.

2
Data Basehistory :
Past medical
The patient has been diagnosed with HIV since 2
months before admission in Sanglah General Hospital.

Family medical History :

- The patient had been take ARV, but it has been
stopped, one month before admisssion, because
of the nausea and vomiting.

Social and family history

- Patient is a merchant
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 Physical Examination
General Severely ill, GCS : 4-5-6
status BW: 51kg H: 150cm ( BMI:normal)
Vital sign BP : 137/90 mmHg HR : 76 bpm
RR : 21 tpm T : 36°C (axilla)
Head & Neck Anemic conjunctiva -/-, Icteric sclera -/-
JVP : R+2 cmH2O
Thorax P : symmetrical, VBS +/+, Rh -/-, Wh -/-
C : ictus at 5th ICS, 1 cm lateral of MCL, single S1/S2, murmur -,
gallop -
Abdomen Flat (+), Soefl (+), Liver : Normal, Lien :Normal, shifting
dullness (+)

Extremities Warm acral, edema +/+

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LABORATORY RESULT

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 HEMATOLOGY 09-10-19 Reference

Hemoglobin 15,20 13,4 – 17,7 g/dL

Erythrocyte 4,96 4,0 – 5,5 . 106 /µL

Leucocyte 7,22 4,3 - 10,3 .103 /µL

Hematocrit 45,30 40 – 47 %
Thrombocyte 423 142 – 424 . 103 /µL
MCV 91,30 80 - 93 fL
MCH 30,60 27 – 31 pg
MCHC 33,60 32 - 36 g/dL
RDW 12,70 11,5-14,5

Diff.count: Eo/Baso/Neut/
1/0/0/58/34/7 0-4/0-1/51-67/25-33/2-5
Lymph/Mono
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 7

Hemostasis
Examination Result Reference
PPT 10,5 9,4-11,3
Kontrol 10,0
INR 1,11 <1.5
APTT 44,10 24,6-30,6
Kontrol 25,9
LABORATORY RESULT
Clinical 09/10 15/10 16/10 17/10 19/10 22/10 Normal
chemistry reference
Urea 54,0 16,6 – 48,5
mg/dL
Creatinine 1,38 < 1,2 mg/dL
eGFR CKD- 70 mL/min/1,73m2
EPI
AST/SGOT 19 0 – 32 U/L
ALT/SGPT 8 0 – 33 U/L
Albumin 1,24 1,22 1,45 1,66 1,52 1,58 3,5 – 5,5 g/dL
RBG 89
< 200 mg/dL

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LABORATORY RESULT
Clinical 10/10 17/10 Normal reference
chemistry
Total <200 mg/dL
Cholesterol 724 478

TG 450 313 <150 mg/dL

HDL >50 mg/dL

Cholesterol 34 29

LDL Cholesterol 648 444 <100 mg/dL

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IMMUNOSEROLOGY 10

Parameter 10/10 Ref. Range

HBsAg COI < 0,9 : Non Reaktif
Reactive
COI ≥0,9 - < 1,0 : Borderline
COI : 738,5
COI ≥ 1,0 : Reaktif
Anti HCV COI < 0,9 : Non Reaktif
Non-reaktif
COI ≥0,9 - < 1,0 : Borderline
COI : 0,067
COI ≥ 1,0 : Reaktif
CD 4 788 637 – 1485
cell/uL
LABORATORY RESULT

Electrolyte 09/10 Normal reference

Natrium 136 133- 148 mmol/L

Kalium 4,25 3,5 – 5,0 mmol/L

Chloride 112 101 – 105 mmol/L

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 Urinalysis 09/10 (09:39) 09/10 (16:25) 12/10 16/10 Reference
Turbidity Turbid Turbid Turbid Clear
Color Yellow Yellow Yellow Yellow
pH 6,0 6,0 6,5 7,0 4,5-8,0
SG 1,025 1,025 1,010 1,015 1,005-1,030
Glucose Negative Negative Negative Negative Negative
Protein 3+ 3+ 3+ 3+ Negative
Keton Negative Negative Negative Negative Negative
Bilirubin Negative Negative Negative Negative Negative
Urobilinogen 3,2 3,2 3,2 3,2 <17μmol/L
Nitrite Negative Negative Negative Negative Negative
Leucocyte Negative Negative 1+ Negative Negative
Blood 3+ 3+ 3+ 3+ Negative
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 Microscopic
09/10 (09:39) 09/10 (16:25) 12/10 16/10 Reference
urine exam
Epithel 1,9 2,4 0,6 4,3 ≤3/lpf
Cast -
10x Hyaline Negative Negative Negative Negative ≤2/lpf
Granular 2-4 1-2 Negative Negative Negative
Other Negative Negative Negative Negative
Erythrocyte 23,0 41,7 319,6 47,5 ≤3/hpf
Eumorphic 38% 34% 96% 64%
Dysmorphic 62% 66% 4% 36%
40x
Leucocyte 8,0 10,0 22,3 6,8 ≤5/hpf
Crystal - - - -
Bacteria 2016,8 1642,4 286,1 634,4 ≤23x103/mL
PCR >500 >500 <80 mg/gCr
ACR >300 >300 <30 mg/gCr
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Electrocardiography (ECG) (8 -10-2019)

• Kesimpulan: Normal Sinus Rhythm, HR 79 bpm

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Renal Biopsy
Conclusion :
- Hyalinosis segmental, focal
- Infiltrat neutrofil
intraglomeruli, focal
- Erithrocyte in the lumen of
tubuli

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Thorax Rontgent (08-10-19)
• AP position  Pleural effusion

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 DATA INTERPRETATION 17

This is a case of a 20-year old male, with laboratory tests showed:

 Azotemia with decreased of eGFR, hypoalbuminemia,
hypercholesterolemia, hypertrigliseridemia.
 Reactive HBsAg
 Proteinuria, increased ACR and PCR, leucocyturia, hematuria, bacteriuria

Based on medical history, physical & other supporting examinations showed

:
1. HIV stage IV co infection with Hepatitis B virus
2. Nephrotic Syndrome
3. Suspected UTI
 Data Interpretations
• Suggestion:
• HIV Confirmation test, HBV DNA, Total protein, globulin, ALP, GGT,
bilirubin T/D/I, urine culture.
• Monitoring : CD 4, CBC, Urynalisis, ALT, AST, electrolytes serum,
ureum, creatinine, lipid profile, albumin, coagulation test.

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Establishment of diagnosis

HIVAN

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Establishment of
diagnosis

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 HIV-AIDS 21

• Acquired Immunodeficiency Syndrome (AIDS) occurs when

infection with the Human Immunodeficiency Virus (HIV)
destroys the immune system.
• A person is defined as infected with HIV when his serum
specimen is reactive in all three anti-HIV antibody tests, which
rely on different antigens or of different operating
characteristics
• Diagnosis of HIV depends on the demonstration of
antibodies to HIV and/or the direct detection of HIV or
one of its components
• A diagnosis of AIDS is made in anyone with HIV infection and a
CD4+ T cell count <200/μL and in anyone with HIV infection
who develops one of the HIV-associated diseases considered
to be indicative of a severe defect in cell-mediated immunity.
WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related
disease in adults and children, 2007.
22
Clinical Stage 1

• Asymptomatic
• Persistent generalized lymphadenopathy

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Clinical Stage 2
• Moderate unexplained weight loss (<10% of presumed or measured
body weight)
• Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and
pharyngitis)
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulceration
• Papular pruritic eruptions
• Seborrheic dermatitis
• Fungal nail infections

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Clinical Stage 3
• Unexplained severe weight loss (>10% of BW)
• Unexplained chronic diarrhea for >1 month
• Unexplained persistent fever for >1 month (>37.6ºC, intermittent or
constant)
• Persistent oral candidiasis (thrush)
• Oral hairy leukoplakia
• Pulmonary tuberculosis (current)
• Severe presumed bacterial infections (e.g., pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis, bacteremia)
• Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
• Unexplained anemia (hemoglobin <8 g/dL)
• Neutropenia (neutrophils <500 cells/µL)
• Chronic thrombocytopenia (platelets <50,000 cells/µL)

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Clinical Stage 4
• HIV wasting syndrome (>10% of BW with prolonged and unexplained fever
or diarrhoea of > 1 month duration)
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (orolabial, genital, or anorectal site for >1
month or visceral herpes at any site)
• Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs)
• Extrapulmonary tuberculosis
• Kaposi sarcoma
• CMV infection (retinitis or infection of other organs)
• CNS toxoplasmosis
• HIV encephalopathy
• Cryptococcosis, extrapulmonary (including meningitis)
• Disseminated nontuberculosis mycobacteria infection

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• Progressive multifocal leukoencephalopathy
• Chronic cryptosporidiosis (with diarrhea)
• Chronic isosporiasis
• Disseminated mycosis (e.g., histoplasmosis, coccidioidomycosis,
penicilliosis)
• Recurrent nontyphoidal Salmonella bacteremia
• Lymphoma (cerebral or B-cell non-Hodgkin)
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy
• Symptomatic HIV-associated cardiomyopathy
• Reactivation of American trypanosomiasis (meningoencephalitis or
myocarditis)

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Immunological staging
of HIV/AIDS in adults
 HIV–HBV Coinfection
• According to the Joint United Nations Program on HIV/AIDS (UNAIDS),
about 33 million people are infected with HIV worldwide, and the
majority of them live in Asia and Africa
• Approximately 10% of the HIV-infected population has concurrent
chronic hepatitis B, with coinfection more common in areas of high
prevalence for both viruses
• In countries where the viruses are highly endemic, the rate can be as
high as 25%

KOURTIS, Athena P., et al. HIV–HBV coinfection—A global challenge. New England Journal of Medicine, 2012, 366.19:
1749-1752.

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This Patient
• 20 y.o male
• Has been diagnosed with HIV since 2 months before admission in
Sanglah General Hospital
• Had been take ARV, but it has been stopped, one month before
admisssion
• Symptomatic HIV-associated nephropathy
• Reactive HBsAg

HIV stage IV co infection with Hepatitis B Virus

• Suggestion : HIV Confirmation test, HBV DNA

• Monitoring: ALT, AST, CD 4

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 Nephrotic syndrome
• Nephrotic syndrome (NS) is a common chronic disorder in
children, characterized by alterations of permeability at the
glomerular capillary wall, resulting in its inability to restrict the
urinary loss of protein.
• Estimates on the annual incidence of nephrotic syndrome range
from 2-7 per 100,000 children, and prevalence from 12-16 per
100,000.
• Definition of NS according to KDIGO 2012:
– edema
– uPCR ≥2000 mg/g (≥ 200 mg/mmol), or ≥300 mg/dl, or 3+
protein on urine dipstick
– hypoalbuminaemia ≤2.5 g/dl (≤25 g/l).**

*Indian J Med Res 122, July 2005, pp 13-28

**Kidney International Supplements (2012) 2, 163–171 31
Etiology

Nephrotic Syndrome

Primary
• Membranous nephropathy
• Focal segmental
glomerulosclerosis (FSGN)
• Minimal change disease
• Membranoproliferative
glomerulonephritis
Secondary
• Diabetic nephropathy
• Systemic Lupus
Erythematosus
• Renal amyloidosis
• Fabry’s disease
Differences Between Primary
nephrotic syndromes
Pathophysiology
This Patient

• 20 yo, male
• Edema
• Azotemia with decreased of eGFR, hypoalbuminemia,
hypercholesterolemia, hypertrigliseridemia
• Proteinuria, increased ACR and PCR

Nephrotic Syndrome

• Suggestion : Monitoring: Ureum, creatinine, albumin,

urynalisis, lipid profile

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HIVAN

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HIV-associated nephropathy (HIVAN)
• Generally recognized as a complication of advanced HIV disease
• Characterized by progressive acute renal failure, often accompanied
by proteinuria and ultrasound findings of enlarged, echogenic
kidneys
• Definitive diagnosis requires kidney biopsy, which demonstrates
collapsing focal segmental glomerulosclerosis with associated
microcystic tubular dilatation and interstitial inflammation.
• Podocyte proliferation is a hallmark of HIV-associated nephropathy,
although this classic pathology is observed less frequently in
antiretroviral-treated patients
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PATHOGENESIS
• The pathogenesis of HIV-associated nephropathy involves :
• direct HIV infection of renal epithelial cells
• the widespread introduction of combination antiretroviral
therapy

• “AIDS nephropathy” had become the third leading cause of ESRD

among African-Americans between the ages of 20 and 64 years (1999)

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This patient
• 20 y.o male
• Nephrotic Syndrome
HIV-associated
• Has been diagnosed
nephropathy (HIVAN)
with HIV since 2
months before
admission in Sanglah
General Hospital Renal USG
• Azotemia Monitoring : Urinalysis, Albumin,
Ureum, Creatinin, CD 4, lipid profile
• Conclusion Renal
Biopsy : Hyalinosis
segmental, focal
CONCLUSION
• It has been discussed, male 20 years old with HIV stage IV co infection
with Hepatitis B virus, Nephrotic Syndrome due to the HIV, and
Suspected UTI
• Nephrotic Syndrome in this patient happen due to the HIV infection
or HIV-associated nephropathy (HIVAN)
• Suggestion : HIV Confirmation test, HBV DNA, Total protein, globulin,
ALP, GGT, bilirubin T/D/I, urine culture, renal USG.
• Monitoring : CD 4, CBC, Urynalisis, ALT, AST, electrolytes serum,
ureum, creatinine, lipid profile, albumin, coagulation test.

40